Ruminations by a non-academic general surgeon from the heart of the rust belt.

Friday, May 20, 2011

Weekend Surgery Puzzle

So a patient comes in with hypotension, tachycardia. His family found him down on the bathroom floor laying in a pool of dark maroon stool. In the ER he is immediately intubated and we resuscitate him with saline and PRBC's. An orogastric tube is placed and massive amounts of blood is evacuated from the stomach. The stomach is then copiously lavaged with saline until clear. An upper endoscopy is subsequently performed that morning which shows 4-5 large duodenal ulcers. But none of them are actively bleeding. No visible vessels are present.

He goes to the ICU on a protonix drip and stabilizes his hemoglobin for 48 hours. Then one Sunday he drops his pressure and starts passing large amounts of blackish-red stool. The GI doc and I are there simultaneously. His blood pressure is tenuous, despite aggressive resuscitation. It seems like he has re-bled from his duodenal ulcers and may need emergency surgery.

But the orogastric tube is putting out bilious contents. The GI guy quickly slips an endoscope into his stomach. And then there's no blood. The ulcers appear stable. Bile washes back from the duodenum.

What is the next step? What operation do you think the dude will need?

If there was no blood in the stomach initially, I would have said there may be a source further down the small bowel or the colon, and the non-bleeding ulcers would have been a red herring. But he had a stomach full of blood. Then a stomach completely clear whilst haemodinamically unstable. Makes me think of another upper GI source that's not readily accesible to endoscopy, such as distal duodenum, proximal jejunum.

So obviously he has an upper GI bleed. 4 duodenal ulcers makes me think of a severe hypergastinemia like Zollinger-Ellison syndrome. Maybe he has a proximal duodenal ulcer that's bleeding or something even in the distal duodenum that wasn't seen on endoscopy. I wouldn't think you could miss intermittently bleeding esophageal or gastric varices either but I suppose it's in the differential for now. There could also be a non ulcer bleeding source in the proximal small bowel such as an AVM, submucosal vessel, etc.

I'm not in medicine, but I think I saw this on an episode of "House." Doesn't he turn out to have a rare genetic disease that can be diagnosed only by a borderline sociopath with the interpersonal skills of a crow? Oh, wait, that's TV.

My non-medical guess: The stomach ulcers are a canard, and not the source of the blood removed from the stomach. Somehow blood is going backwards from the bleed and getting back into the stomach, as well as out in the normal direction. That's some serious bleeding!

I'll be amazed if that's anywhere close to the truth. I'm barely qualified to put on a band-aid!

OK, maybe I've been listening to too much Journey/Night Ranger/Bangles but.......Highly selecive vagotomy with pyloroplasty/any other indicated procedures...You were born 20 years too late Buckeye...the Operations they used to do in the 80's...made even ME want to be a Surgeon.OK, I can't tie my own shoes, but I could hold a retractor like a Mo-Fo..and I can still remember my first Subclavian line...actually it was my second, but you couldn't count the ones where you dropped a lung.it was whatever date Geraldo Rivera opened Al Capone's vault.Now its all scopes and staplers and "interventional" procedures...I'll take a good old fashioned ER thoracotomy anyday...Ever see a lefty try to crack a chest? I gave the gas passer a nasty elbow to the nose...

@Wayne.... apparently he was diagnosed by a borderline sociopath with the interpersonal skills of a crow.. AKA .. Buckeye Surgeon .. Bam! Oh ya... I just went there! I took it downtown.. phi slama jama! :)

Who the heck knows the diagnosis. But one thing I've learned.. I don't go flying to the OR without knowing where this patient is bleeding from. It still can be anywhere from Dude to Anus.. But given the character of output, it is most likely upper GI.

Since you posted this.. it must is likely something more uncommon. Therefore, the two likely sources are: jejunal diverticular bleeding or aorto-enteric fistula from previous aortic bypass surgery.

An ischaemic left colon does not explain a stomach full of blood (and there's no report of stress ulceration). Ischaemia is sort of the least likely cause of bleeding, isn't it...

I still lean toward an upper GI problem. How old is this guy? Could he have some fancy (retroperitoneal) tumor involving the IMA (hence some left colon ischaemia), plus some sort of vascular-enteric fistula?

An arteriography would help, definitely. Also, there's OR in this man's very near future, undoubtedly.

As for "what operation", it is impossible to say more than "diagnostic laparotomy" at this point.

- PR bleed with fresh blood, no bleeding source in distal colon- bleeding a lot, fast (haemodinamically unstable)- had a stomach full of blood

All of these suggest a foudroyant upper GI bleed that's not in the stomach/proximal duodenum. I cannot rule out a proximal colon bleed, but I think it's unlikely to have a haemorrhage of this amplitude from the colon, unless you definitely excluded distal duodenum and small bowel.

What I'd do is push for an angiogram +/- embolization, if it doesn't take too long, also attempt some investigation of the distal duodenum (perhaps a more experienced uooer GI endoscopist woul be able to intubate it) and proximal jejunum.

All of these with a mind set to OR, soon. The problem with going in without an established source, in this particular situation, is that you might find yourself in a situation where all you see is bowel full of blood, from the DJ flexure to the rectum, nil else. Where's the bleed?

The fact that he requires Vassopresin now, despite fluid resus and transfusion, makes me think that bleed really is brisk. This does not sound like something that'll settle conservatively.

Also, I do think that if all the above fails or can't be done soon enough, his only hope is to be taken to theatre, although, without having actually identified the issue first, I wouldn't like to be in your shoes.

PS: could this be something idiotic and unheard of, such as a toothpick going through the duodenum into the SMA (or worse)? You know very well people never cease to amaze doctors. I assume he's had an abdo Xray.

Well the flex sig showed pretty much a dead left colon. So that sort of bugged me. And his henoglobin hadn't dropped below 8. So I was wondering if maybe his hypotension wasn't related to some extent to sepsis from the ischemic colitis.

I took him to "theater" and opened him wide. The left colon was shriveled and gnarled and indurated, with patchy areas of frank necrosis, consistent with ischemic colitis. So I chopped out the left colon and gave him a transverse colostomy. I assumed that his second bleed was related to the colitis but his initial presentation (massive blood upon OG suctioning) gnawed at me. So I did a truncal vagotomy/pyloroplasty before closing him up.

He did reasonably well post op. Importantly, he never rebled.

So there wasn't anything fancy about the case; no zebras or crazy one in a million diagnoses. This was all pretty standard, straight forward general surgery business. But the decision making was TOUGH.

I suspect the guy presented with a major UGI bleed due to the duodenal ulcers. And the hypotension, hemodynamic lability that occured during the initial resuscitation phase may have precipitated the ischemic colitis, leading to the second major bleed.

I guess the lesson is that even the routine situations can be problematic. You have to be systematic and rely on fundamentals at ALL stages of the hospital course. Whenever a patient rebleeds, you canm't always assume he's bleeding from the identical location. Go back to the beginning. Start over. Go through your algorithms.

I agree with the scenario involving ischaemic colitis precipitated by the blood loss, it's very sensible.

The source being the ulcers is also the most likely. Perhaps there was never a re-bleed, perhaps him becoming haemodinamically unstable was nothing but a bump during resuscitation, and the blood coming from down below is simply residual from the initial massive bleed. This is all supported by the haemoglobin remaining stable. If he re-bled, it would have definitely come down (the Hb is new information though, and I dared not ask, questioning you like a medical student, and I automatically assumed it was steadily dropping - that goes to show the traps of working on assumptions).

I think it's pretty safe (for now) to attribute the large number of ulcers to his chronic renal failure, and forget (or postpone) the Zollinger-Ellison investigation.

As for your management, I think the best part was going to theatre, and I have to agree, the desision was TOUGH (in capitals). The colectomy was a no brainer, stoma also. However (and I only say this because I'm safely away from your patient), I think I might have stayed away from the stomach at this point (bleeding stopped already, high-risk patient already having another major operation, I would have gone with medical management for now).

Thanks for sharing this, very interesting and educational. I hope this patient gets well.

Sounds like everything went well in the end. When things became less clear, i.e., after the 2nd bleed, perhaps the radiologist could have been consulted. At my institution, they roll their eyes at the tagged RBC scan but will happily do a mesenteric CT angiogram for a complex case like this... then they repeat the scan a few seconds later in portal venous phase.

Especially with the two phases of contrast enhancement, this is pretty good at picking out fairly subtle bleeds and gives you a better overall look at the abdomen as well compared to a conventional angiogram.

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